Anesthesia Coding Alert

Question: When using 00563 (which includes hypothermic circulatory arrest in the descriptor), is it incorrect to also bill hypothermia code +99116 at the same time? Our confusion is stemming from the verbiage associated with 00561. Although 00561 is for a patient under one year of age and does not include hypothermic circulatory arrest in the descriptor, a note with the code states not to report 00561 in conjunction with +99100, +99116, and +99135. The verbiage for 00563 does not state that you cannot bill +99116 with it, and that is our dilemma.

Connecticut Subscriber

Answer: You can check with the patient’s insurance company to be sure of their rules, but the American Society of Anesthesiologists (ASA) Relative Value Guide® (RVGTM) indicates 00563 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest) is one of the codes that includes the qualifying circumstances add-on codes, such as +99116 (Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)).

In other words, according to ASA RVGTM rules, you should not report +99116 in addition to 00563. The higher base units for many of the heart codes (like 00563) take into consideration procedure-associated difficulties, so you should not double dip by reporting qualifying circumstances add-on codes +99116, +99135 (Anesthesia complicated by utilization of controlled hypotension …), and +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 …).

In addition to 00563, the codes the ASA RVGTM lists that include qualifying circumstances codes +99100, +99116, and +99135 are:

• 00561 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age)
• 00562 (… with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after original operation)
• 00567 (Anesthesia for direct coronary artery bypass grafting; with pump oxygenator)

In the CPT^® code book, only 00561 has a note that specifies you should not report it in conjunction with +99100, +99116, and +99135, and some payers may follow suit. But keep in mind that 00563 includes hypothermic circulatory arrest in the descriptor, so you can expect that code and its fee to already include the time and work required for hypothermia.

Medicare: There is not a Medicare National Correct Coding Initiative (NCCI) edit preventing you from reporting 00563 with +99100, +99116, and +99135, but those qualifying circumstances add-on codes have code status B on the Medicare Physician Fee Schedule. That means payment for those codes is always bundled into payment for other services.